In the more aggravated cases of cancerous disease which involve the whole of the cervix up to or beyond the internal os, and which are asso ciated, as so often happens, with infiltration and degeneration of the sur rounding cellular tissue, it may be asserted that spontaneous delivery is impossible. The dense, infiltrated parts offer an insuperable resistance, and the pains are not powerful enough to crush the intervening tissues. If timely operative assistance be not afforded the patients die undelivered from rupture of the uterus, hemorrhage, or septicaemia originating gener ally in decomposition of the fcetus, or exhaustion. Such cases have been described by Depaul,' Churchill,' Oldham,' Simpson,' and Pfannkuch.° The character of the subsequent period of childbed in these cases depends chiefly upon the gravity of the labor. If the latter have occurred spontaneously and without much difficulty, the women often make won derfully quick recoveries, and sometimes even become pregnant once more (Savory-Godson, I. c.), only to succumb to their disease after a longer or shorter time. In most instances, however, and even after a comparatively easy confinement, the disintegration of the cancerous tissue acquires a fresh impetus, and the patients rapidly sink under the exhausting influence of child bed. The more difficult the labor, the more frequently and the more rapidly does childbed run this course; the larger the mass of cancerous tissue destroyed, and the deeper the coincident lacerations, the more quickly does necrosis extend in all directions, to be followed by fatal peritonitis, pymmia, thrombosis, etc. Heywood Smith ° lost a patient affected with epithelioma, from post-partum hemorrhage, four days after spontaneous expulsion of a five months' fcetus In Edis" and Depaul's cases death was due to pyTmia and septicemia.
The diagnosis of cancerous disease of the lower segment of the uterus during pregnancy or parturition can only be difficult when the affection is in its incipiency. I have already discussed the possible sources of error, and will now only repeat that mistakes may occasionally be committed in spite of the utmost care. Imperfect or delayed dilatation of the os in parturient females may be a guide to a certain extent, but even here it is necessary to guard against error. Newman's case is very instructive in this connection. The os not dilating and the cervix being extremely hard and infiltrated, carcinoma was diagnosed, and Caesarean section performed, from which, fortunately, the patient recovered. Becoming pregnant again six years later, the woman was easily delivered with the forceps of a mature child. Two years afterwards she died of a strangulated ventral hernia (the result of the Cesarean section), and no trace of cancerous dis ease was discoverable on post-mortem examination. This case would scarcely be classed as one of spontaneous cure of cancer of the uterus.
Among other errors, the degenerated parts have been mistaken at the commencement of labor for the placenta (Lachapelle, Lecorche-Colonitrat, Chantreuil, 1. c. p. 56), for festal hands and feet (Depaul, Commix% for the child's head (Boivin and Dues), and for the breech (Chantreuil, 1. c.
page 56). But in all of these cases careful and repeated examinations soon cleared up the diagnosis.
It is evident from the foregoing that the prognosis of carcinoma of the uterus during pregnancy and at the time of parturition depends mainly upon the extent of the disease. The greater it is, the more difficult will confinement be. A second weighty factor is the general condition of the patient. If but slight indications of cachexia are present the patient's chances of surviving labor and childbel are better than if a high degree of antemia and cachexia already exist. In Chantreuil's collection of sixty cases, twenty died during or immediately after confinement, the remainder passing through this ordeal safely, but eventually succumbing to the dis ease. Of these twenty-five patients, six perished in consequence of rupture of the uterus, nine from peritonitis, and seven after grave operative measures, including multiple incisions, version, craniotomy, embryotomy, and excision of the tumor: the cause of death is not mentioned in three instances. Of the children twenty-nine were born dead, and twenty-eight alive, while nothing is stated of the fate of three others.
Cohnstein found that of one hundred and twenty-six mothers fifty-four, or 42.9 per cent., survived childbed, the remainder dying daring or after labor. Of one hundred and sixteen children, concerning whom informs Ilion was obtainable, forty-two, or 36.2 per cent., were born alive, and seventy-four, or 63.8 per cent., were still-born. Of the latter class seven were killed by perforation or embryotomy, one, a six months' fmtus, was delivered by Caesarean section. fourteen died in consequence of the death of the mothers before delivery was accomplished, and six perished during tedious labors, or after version, etc.
By eliminating these deaths, as being consequences of treatment and not of the disease itself, Cohnstein finds that the mortality of the children in cases of cancer of the uterus is only 38.8 per cent. This elimination, however, is not entirely justifiable, inasmuch as the method of treatment, whether appropriate or not in the individual cases, was prompted mainly by the complicating disease.
From Herman's figures we learn that out of 180 cases, the mothers succumbed in seventy-two. Eleven times death was due to rupture of the uterus. In thirteen women death took place before delivery. Of 114 children, fifty-eight were born alive.
When an epithelioma is restricted to one lip of the cervix there is reason to hope, for reasons above-stated, that labor will be accomplished spontaneously, and treatment should, therefore, for the time being be merely expectant. In all other cases, however, active interference is imperatively required, as soon as it is noticed that the diseased os is dilat ing imperfectly and slowly, in spite of regular pains. Delay in these cases is always fatal to the foetus, and since the mother's disease is incurable, our efforts should be directed to saving the life of the child.